Provider Demographics
NPI:1790998235
Name:MILLER, MARY ANN (LICSW)
Entity Type:Individual
Prefix:MS
First Name:MARY ANN
Middle Name:
Last Name:MILLER
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2720 W 43RD ST
Mailing Address - Street 2:#204
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55410-1643
Mailing Address - Country:US
Mailing Address - Phone:612-920-9550
Mailing Address - Fax:
Practice Address - Street 1:2720 W 43RD ST
Practice Address - Street 2:#204
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55410-1643
Practice Address - Country:US
Practice Address - Phone:612-920-9550
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN94231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical